A 2-week-old infant born at 26 weeks’ gestation died in the NICU after hours of increasing support and resuscitation. In the day preceding diagnosis, the infant had an increase in oxygen requirement, a heart rate increase, and a rise in a displayed continuous sepsis risk score. These changes were noted but attributed to other interventions and events that had occurred during the day. Later, the nurse paged the team to the bedside when the infant developed tachycardia, hypotension, and diffuse purpura. The team ordered a blood culture and antibiotics, but it was too late. In the modern era of advanced medical analytics and monitoring, it might seem unlikely for bacteremia to slip by undetected until it presents as fulminant sepsis with multiple organ failure. Even the most sophisticated analytics and monitoring systems cannot function without a clinical eye, which can be impeded by intangible barriers, particularly in pediatrics. Recent attention...

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